Histrionic personality disorder

Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriate seductiveness, usually beginning in early adulthood. These individuals are lively, dramatic, enthusiastic, and flirtatious.

They may be inappropriately sexually provocative, express strong emotions with an impressionistic style, and be easily influenced by others. Associated features may include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behavior to achieve their own needs.

Characteristics

People with this disorder are usually able to function at a high level and can be successful socially and professionally. People with histrionic personality disorder usually have good social skills, but they tend to use these skills to manipulate other people and become the center of attention. Furthermore, histrionic personality disorder may affect a person's social or romantic relationships or their ability to cope with losses or failures.

People with this disorder lack genuine empathy. They start relationships well but tend to falter when depth and durability are needed, alternating between extremes of idealization and devaluation. They may seek treatment for depression when romantic relationships end, although this is by no means a feature exclusive to this disorder.

They often fail to see their own personal situation realistically, instead tending to dramatize and exaggerate their difficulties. They may go through frequent job changes, as they become easily bored and have trouble dealing with frustration. Because they tend to crave novelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing depression.

Additional symptoms include:

• Exhibitionist behavior.
• Constant seeking of reassurance or approval.
• Excessive dramatics with exaggerated displays of emotions, such as hugging someone they have just met or crying uncontrollably during a sad movie (Svrakie & Cloninger, 2005).
• Excessive sensitivity to criticism or disapproval.
• Inappropriately seductive appearance or behavior.
• Somatic symptoms, and using these symptoms as a means of garnering attention.
• A need to be the center of attention.
• Low tolerance for frustration or delayed gratification.
• Rapidly shifting emotional states that may appear superficial or exaggerated to others.
• Tendency to believe that relationships are more intimate than they actually are.
• Making rash decisions.

Causes

The cause of this disorder is unknown, but childhood events such as deaths in the immediate family, illnesses within the immediate family which present constant anxiety, divorce of parents and genetics may be involved. Histrionic Personality Disorder is more often diagnosed in women than men; men with some quite similar symptoms are often diagnosed with narcissistic personality disorder.

Little research has been conducted to determine the biological sources, if any, of this disorder. Psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly mother) or both of the parents of these patients, or love based on expectations from the child that can never be fully met.

Diagnosis

The person's appearance, behavior, and history, along with a psychological evaluation, are usually sufficient to establish the diagnosis. There is no test to confirm this diagnosis. Because the criteria are subjective, some people may be wrongly diagnosed as having the disorder while others with the disorder may not be diagnosed. Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect this personality disorder, but may be helpful with symptoms such as depression. Psychotherapy may also be of benefit.

DSM-IV-TR 301.50

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines histrionic personality disorder (in Axis II Cluster B) as:

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. is uncomfortable in situations in which he or she is not the center of attention
2. interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
3. displays rapidly shifting and shallow expression of emotions
4. consistently uses physical appearance to draw attention to self
5. has a style of speech that is excessively impressionistic and lacking in detail
6. shows self-dramatization, theatricality, and exaggerated expression of emotion
7. is suggestible, i.e., easily influenced by others or circumstances
8. considers relationships to be more intimate than they actually are.

It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

ICD-10

The World Health Organization's ICD-10 lists histrionic personality disorder as (Template:ICD10) Histrionic personality disorder.

It is characterized by at least 3 of the following:

1. self-dramatization, theatricality, exaggerated expression of emotions;
2. suggestibility, easily influenced by others or by circumstances;
3. shallow and labile affectivity;
4. continual seeking for excitement and activities in which the patient is the center of attention;
5. inappropriate seductiveness in appearance or behavior;
6. over-concern with physical attractiveness.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Millon's subtypes

Theodore Millon identified six subtypes of histrionic. Any individual histrionic may exhibit none or one of the following:

• Theatrical histrionic - especially dramatic, romantic and attention seeking.
• Infantile histrionic - including borderline features.
• Vivacious histrionic - synthesizes the seductiveness of the histrionic with the energy level typical of hypomania.
• Appeasing histrionic - including dependent and compulsive features.
• Tempestuous histrionic - including negativistic (passive-aggressive) features.
• Disingenuous histrionic - antisocial features.

Mnemonic

A mnemonic that can be used to remember the criteria for histrionic personality disorder is PRAISE ME:

• P - provocative (or seductive) behavior
• R - relationships, considered more intimate than they are
• A - attention, must be at center of
• I - influenced easily
• S - speech (style) - wants to impress, lacks detail
• E - emotional lability, shallowness

• M - make-up - physical appearance used to draw attention to self
• E - exaggerated emotions - theatrical

Differential diagnosis

• Clinical depression
• Anxiety disorders
• Panic disorder
• Somatoform disorders

A person suffering from HPD is highly reactive. If there is another major disorder present, such as delusional disorder, then emotional intensity will create anger, rage, abuse and distance in relationships.

It is important for the therapist and family members to monitor and record all situations that trigger the HPD so that the deep underlying overload of pain can be accessed and released for therapeutic change.

Treatment

Because of the lack of research support for work on personality disorders and long-term treatment with psychotherapy, the empirical findings on the treatment of these disorders remain based on the case report method and not on clinical trials. On the basis of case presentations, the treatment of choice is psychotherapy and/or cognitive-behavioral therapy, aimed at self-development through resolution of conflict and advancement of inhibited developmental lines. Group therapy can assist individuals with HPD to learn to decrease the display of excessively dramatic behaviors, but must be closely monitored because it may provide the person with an audience to play to (perform for), thus giving opportunity to perpetuate histrionic behavior.

• Family therapy
• Medications
• Alternative therapies
• Cognitive behavioral therapy

Epidemiology

Major character traits may be inherited. Other character traits due to a phenotypical combination of genetics and environment, including childhood experiences

History

Histrionic personality disorder shares a divergent history with conversion disorder and somatization disorder. Historically, they are linked to the ancient notion of hysteria, or "wandering womb."(Note, however, that according to the Online Etymology Dictionary, the word "histrionic" derives not from the Greek hystera, but from the Latin histrionicus, "pertaining to an actor.") Ancient Greeks thought that excessive emotionality in women was caused by a displaced uterus and sexual discontent.

Christian ascetics during the Middle Ages blamed women's mental problems on witchcraft, sexual hunger, moral weakness, and demonic possession. By the 19th century, medical explanations proposed a weakness of women's nervous system related to biological sex. Thus, "hysteria" reflected the stereotype for women as vulnerable, inferior, and emotionally unbalanced. The extent to which the definition of histrionic personality disorder currently reflects gender bias remains the subject of controversy.

"Hysteria" differentiated into conversion hysteria (later to become conversion disorder) and hysterical personality (later to become histrionic personality disorder) in the psychoanalytic literature as well as with the writings of Kraepelin, Schneider, and others. Sigmund Freud wrote primarily about conversion hysteria. Wilhelm Reich wrote about hysteria as a set of personality characteristics and differentiated conversion hysteria as a transient disorder from hysterical character. These early conceptualizations of both kinds of hysteria carried notions of women's deficiency due to penis envy and feelings of castration. Paul Chodoff has written about the ways in which these diagnoses paralleled the misogynistic sentiment of the times.

The concept of hysterical personality was well developed by the mid-20th century and strongly resembled the current definition of histrionic personality disorder. The first DSM featured a symptom-based category, "hysteria" (conversion) and a personality-based category, "emotionally unstable personality." DSM-II distinguished between hysterical neurosis (conversion reaction and dissociative reaction) and hysterical (histrionic) personality.

In DSM-III, the term hysterical personality changed to histrionic personality disorder to emphasize the histrionic (derived from the Latin word histrio, or actor) behavior pattern and to reduce the confusion caused by the historical links of hysteria to conversion symptoms. The landmark case of Ruth E. helped to fully define and emphasize the characteristics of the current DSM-IV diagnostic. DSM-III-R attempted to reduce the overlap between Histrionic Personality Disorder and borderline personality disorder by dropping three overlapping criteria and adding two criteria that emphasized histrionicity. DSM-IV dropped two more criteria that did not appear to contribute to the consistency of the diagnosis, according to research done by Bruce Pfohl.